Medicaid Fraud

Under the Medicaid program, taxpayer dollars are used to provide health care to low-income individuals. It is vital that these dollars be effectively spent to help those in need. Unfortunately, a small percentage of Medicaid providers and recipients engage in various forms of fraud and abuse.

Fraud and abuse affects everyone - the recipients of care, the taxpayers who pay for it and the vast majority of providers who provide quality care. Each dollar lost to fraud is one less dollar available for someone in need of care.

There are several types of Medicaid fraud committed by providers or recipients. They are described below. If you think you know of someone who is abusing the Medicaid program, you should report it. There are several ways to contact us and, if you prefer, you may do so anonymously. The sources of all fraud referrals are kept strictly confidential.

The Department of Health is committed to eliminating all forms of healthcare fraud and abuse. We need your help to accomplish this.

Recipient Fraud

A small percentage of recipients engage in fraudulent behavior and abuse their Medicaid privileges. The Health Department's Office of Medicaid Management reviews recipient utilization and investigates other charges of fraudulent behavior in order to take appropriate actions. Some types of recipient fraud, such as forging prescriptions, are subject to prosecution and will be referred to the appropriate authorities.

Examples of Fraud

Medicaid recipient fraud can take several forms and we need the cooperation of diligent providers and Medicaid recipients to uncover this type of activity. Among the kinds of actions that constitute recipient fraud are:

  • Loaning his/her Medicaid Identification card to another person;
  • Forging or altering a prescription or fiscal order;
  • Using multiple MA ID cards;
  • Intentionally receiving duplicative, excessive, contraindicated or conflicting health care services or supplies; and
  • Re-selling items provided by the Medicaid program.

How to Report Recipient Fraud

If you suspect that a recipient has engaged in any of the activities listed above or any other questionable activity, please call 1-877-87FRAUD, (1-877-873-7283). Your call will remain confidential. In addition there is a mail-in complaint form (PDF, 163KB, 1pg.) which can be used to file a complaint. Please mail the complaint to:

State of New York
Office of the Medicaid Inspector General
Bureau of Investigations & Enforcement
Riverview Center, 150 Broadway
Albany, New York 12204
Web site: http://www.omig.state.ny.us

Provider Fraud

A small number of Medicaid providers engage in fraudulent activities. The Office of Medicaid Management reviews provider billing and other activities and investigates charges of fraudulent behavior in order to take appropriate actions.

Examples of Provider Fraud

Medicaid provider fraud has many forms and we need the cooperation of diligent providers and Medicaid recipients to uncover this type of activity. One way for a recipient of medical services to assist us in identifying fraud is to keep a record of the following:

  • When a professional service is used;
  • Where the service takes place;
  • Who takes care of you;
  • What services are provided during the visit; and
  • What additional services were ordered by the provider.

If a recipient suspects that a provider has billed Medicaid for more services than were actually provided, that would be fraud.

Some examples of provider fraud include:

  • Billing for services that were not provided, e.g., a chest x-ray that was not taken.
  • Duplicate billing which occurs when a provider bills Medicaid and also bills private insurance and/or the recipient.
  • Requiring the recipient to return to the office for more visits when another appointment is not necessary.
  • Taking unnecessary x-rays, blood work, etc.
  • Upcoding, e.g., providing a simple office visit and billing for a comprehensive visit.
  • Having an unlicensed person perform services that only a licensed professional should render, and bills as if the professional provided the service.
  • Billing for more time than actually provided, i.e., counseling, anesthesia, etc.
  • Billing for an office visit when there was none, or adding additional family members' names to bills.
  • Accepting payment from another provider, including sharing in the reimbursement paid by the Medicaid program, as a result of referring a patient to the other provider.

How to Report Provider Fraud

If you suspect that a provider has engaged in any of the activities listed above or any other questionable activity, please call 1-877-87FRAUD, (1-877-873-7283). Your call will remain confidential. In addition there is a mail-in complaint form (PDF, 166KB, 1pg.) which can be used to file a complaint. Please mail the complaint to:

State of New York
Office of the Medicaid Inspector General
Bureau of Investigations & Enforcement
Riverview Center, 150 Broadway
Albany, New York 12204
Web site: http://www.omig.state.ny.us

Questions

Any questions may be directed to the Hotline at 1-877-873-7283

Medicaid Complaint Form (PDF, 166KB, 1pg.)